Musings in the life of an internist, cardiologist and cardiac electrophysiologist.

Thursday, October 27, 2011

Medicine's Holiday Crunch

Like Christmas season advertising, the holiday crunch for procedural medicine is coming earlier every year.

Perhaps that's why the posting on this blog as suffered: we're busier than ever.

Why is this?

I suspect it's because of a variety of forces that are coming together to create the great procedural "perfect storm" this time of year.

Perhaps the most important contributor to the holiday rush is the patients themselves. Patients are feeling the effects of their higher health insurance costs like never before. Higher co-pays and annual deductible amounts are making them frantic to get their high-ticket procedures performed before year's end to avoid paying an even higher deductible amount next year.

Additionally, staff want to take vacation this time of year. This puts constraints on specialist's lab time availability. It's a supply-side bottleneck. To relieve the crunch, the same staff are finding themselves working longer and longer days already.

No doubt the government regulators and hospital administrators are enjoying the fruits of their regulatory victory. Seriously, how could it get better? More cases, same staff, lots of new "efficiencies."

Bada bing, bada boom!

But there's a catch. Maybe not now, but sometime soon. We've seen inklings of it - nothing big in the grand scheme of things, mind you, but inklings nonetheless: workers are getting frayed. Since hospitals work to keep overhead costs low in anticipation of still more cuts to government payments, hiring has slowed. Burnout of existing staff is a real concern. Not just with doctors, but ancillary staff, too.

So far, our new health care system has been engineered to take care of lots and lots of patients. To this end, they are succeeding. But as this holiday crunch continues this year and beyond, the pop-off valve to our new health care delivery system pressure-cooker remains the doctors, nurses, and other ancillary personnel workers who work tirelessly to Feed the Beast. Add to this the fact that our providers are increasingly regulated into forced behaviors without concern to the additional time that these regulations require. There seems to be more time spent on regulation requirements ("performance measures", and the like) in exchange for less time for patients and less time for home. As a result, all our direct providers of health care (nurses, doctors and ancillary staff) remain our new health care system's weakest and most vulnerable link.

And what happens when these worn out, burnt out, overbooked workers make an error as overstressed structures do?

In our increasingly regulated medical world, increasingly it seems that the regulators never have to bear the brunt of the time required to implement their regulations. Even with safety measures, for instance, our regulators are convinced that their regulations improve safety, and for a while, a specific safety measure often "works." But as more and more safety measures are added, old safety measures take a back seat to the latest trendy ones as surgeons push to get their cases done.

Time can't be regulated and every regulation adds time to the doctors' day. We have yet to figure out how to add more than 24 hours to the day. As such, more regulations might help for a while, but the long term benefits to the doctors who provide the care and on whom the regulatory burdens inevitable fall, remains suspect.

But always more administrators, however. I notice that your wonderful medical group now has 3 assistant vice presidents in addtion to your president that runs the medical group. So don't worry; there will be plenty of people to count all the extra income you and your staff generate!

I couldn't agree more. However, it does beg the questions of what can be done about this? I have a few suggestions.

First, what can the hospitals do?

1. A massive overhaul of their regulations and procedures. Cut out the needless regulations and inevitable double ups. This may be costly so let me put it in a context bureaucrat would understand:

Regulations + Paperwork = Time = Money

Therefore streamlining regulations would save money.

2. Take pressure off the doctors and nurses. A great deal of non-essential tasks are delegated to these people. Some of these tasks could be delegated elsewhere, leaving the doctors and nurses to do what they do best, medicine.

3. Add incentives for staff not to take holidays during the lead up to Christmas.

What can the government do?

4. Write legislation to streamline government regulations.

5. Align the medical year with the financial year. This will move the financial incentive to have surgery pre Christmas to a more manageable time of year.

What can the patient do?

6. Be aware of the Christmas log jam and elect to have your procedures outside of this time.

7. Take charge of your own treatment. Many accidents happen and are blamed on hospitals, doctors etc, but could have been prevented by the patient. As a patient, pre surgery I like to have a short 30 second conversation with my surgeon just to make sure he has bought his 'A' game. For a number of reasons (tired, stressed, emotional, ill, hung over.....) they might be off their game and I would have no hesitation in postponing the surgery. This has never happened to me with a surgeon, but one I did have a scrub nurse who had just broken up with her boy friend and was an emotional mess. I told the surgeon I didn't want her in the OR and they removed her without any fuss. If I had said nothing she would have played a part in my surgery and who knows what mistakes she would hjave made.

What can the doctors do.

8. I actually think nothing, it is up to the system to allow them to do what they do best. If anything they should be making sure they are allowed to

While the medical workforce is aging chronologically with the rest of the population, it is aging physically and emotionally much faster.

Even with the poor economy, most providers are seeing the mega trends and are planning their exit strategies.

The improvement in their economic circumstance which will accompany an even modest improvement in the general economy will provide the opportunity for a significant minority of the most experienced to drop to part time practice or become non-clinical entirely. This at a time when demand for medical care will explode.

Fortunately, the government has an infinite supply of ever shrinking dollars to throw at the problem.....otherwise I would be concerned.

While the medical workforce is aging chronologically with the rest of the population, it is aging physically and emotionally much faster.

Even with the poor economy, most providers are seeing the mega trends and are planning their exit strategies.

The improvement in their economic circumstance which will accompany an even modest improvement in the general economy will provide the opportunity for a significant minority of the most experienced to drop to part time practice or become non-clinical entirely. This at a time when demand for medical care will explode.

Fortunately, the government has an infinite supply of ever shrinking dollars to throw at the problem.....otherwise I would be concerned.

A few years ago I had not seen my first EP for almost a year and when I did he looked like walking dead. I mentioned it as respectfully as possible... something like he might benifit from a vacation. I got a look that said it all and soon he made an excuse to let one of his partners take my case. Later I left the entire practice as the medical files where stacked up on top of the file cabinets and in along the walls of the office. The quality of care had been replace by the amount of $ to be made and I think everyone was suffering...

Shakesandstones said..." A massive overhaul of their regulations and procedures."Sounds simple, doesn't it? Most of this is federally mandated. Now, give me a solution!Dennis said..."The quality of care had been replace[d] by the amount of $ to be made... "Did you ever stop to think that no one had time to deal with those charts because everyone was tied up either seeing patients (you know, they don't like to wait); getting prior authorization from insurance companies for scans, etc.; explaining written material provided to the patient by government mandate; answering requests from patients; re-filling prescriptions; reviewing lab results; reviewing x-rays; talking by phone with patients about their lab and x-ray results; consulting with another physician about a patient; documenting everything the government requires; resolving staff conflicts; training new employees; doing double-duty when someone is out sick; filing insurance claims FOR THE PATIENT; arguing with a 20 year-old insurance company clerk who was hired last week and won't be there next week; or maybe just taking a dump! You may be retired and have all the time in the world, just like my mother, but not everybody has that luxury! While people are treating you with extra time and kid gloves, the patient in the next room is bitching about why they haven't been seen, yet.Elaine Schattner, MD said..."... wouldn't that support more checks on the system?"And who would be responsible for implementing those new checks. There are only a certain amount man-hours (is that politically incorrect?) to be had in a day, and those employees have to be payed.Maybe our messianic president can, by executive order, bypassing congress, mandate a 28 hour day and give us all robotic employees, who don't expect a wage, never tire, never have PMS or its male equivalent, never get sick, not have kids with dental appointments, have no personal problems, and never make mistakes, i.e., totally inhuman.In fact, Watson could provide Dennis with a smiling "face," no emotions, and likely be reviewing other data simultaneously (multitasking with those extra core processors), answering the phone, etc., while other, less expert robots could be scanning those charts into the EMR!Now, if we could manufacture these robots here... Not! They'd all be made in China! Would they have to pass the ECFMG? But I digress.

One simple solution would be to quit making everyone's deductibles restart at the same time, Jan. 1 each year. My insurance plan "year" starts Sept. 1; why, then, does my deductible restart Jan. 1? If the deductible year matched the enrollment year (and the enrollment year were tied to actual date of enrollment instead of forcing everyone in the company to reenroll at the same time), these deductible deadlines would be much better distributed throughout the year, easing the year-end crunch. And it's a simple fix that I don't believe requires getting those barnacles in the arse of progress we call Congress to actually do anything.

thought you would appreciate this young artists (David Foox) work in raising awareness for organ donation. His creepy cute toys stand 3.25" tall and are one of 24 different body parts. http://organ-donors.us

About Me

Westby G. Fisher, MD, FACC is a board certified internist, cardiologist, and cardiac electrophysiologist (doctor specializing in heart rhythm disorders) practicing at NorthShore University HealthSystem in Evanston, IL, USA and is a Clinical Associate Professor of Medicine at University of Chicago's Pritzker School of Medicine. He entered the blog-o-sphere in November, 2005.
DISCLAIMER: The opinions expressed in this blog are strictly the those of the author(s) and should not be construed as the opinion(s) or policy(ies) of NorthShore University HealthSystem, nor recommendations for your care or anyone else's. Please seek professional guidance instead.